Jaimanti Bakshi

Rhinocerebral mucormycosis: the disease spectrum in 27 patients

The variable forms of clinical complaints, findings and time interval of presentation in 27 cases of mucormycosis have been described, which were encountered over a span of 8 years. The previous concept about this fungal infection attacking chronic, debilitated, immunocompromised patients does not appear to hold true. Seven of the 27 patients (22.2%) did not reveal any predisposing factors and their outcome of 42.9% survival seems to be poorer than the total outcome (66.7%). ‘Chronic form’ of disease presentation, the definition of which is still not delineated, was encountered in four patients (14.8%). Again, the outcome was not significantly different from the total survival. Burr‐hole tap of an intracranial abscess revealing mucor in a 2‐month‐old infant has been described. Even in the present era, extranasal exenteration of sinuses along with disfiguring orbital exenteration is required to ensure satisfactory surgical debridement. Control of the underlying predisposing illness, along with the aggressive surgical debridement and the parenteral administration of amphotericin B, remains the treatment essentials even today.

Migratory foreign body of neck in a battered baby: a case report

Only a small number of ingested foreign bodies perforate the esophagus and even smaller fraction migrate extramucosally with no symptoms. Both of these events are even rarer after marble ingestion. We report here a case of battered baby with homicidal marble ingestion which perforated the esophagus and migrated into the soft tissue of neck. It was diagnosed after 21 days asymptomatic period. The foreign body migrated into the tracheo-esophageal groove, lying deep to strap muscles, which was removed by neck exploration.

Head and Neck Leiomyosarcoma

Soft tissue sarcomas of head and neck region, account for 4–15% of all soft tissue sarcomas and less than 1% of all neoplasms in this region. Leiomyosarcoma is malignant tumor of smooth muscle which accounts for only 4% of head and neck sarcomas. The tumor is commonly encountered as a slow growing, discrete firm, and non-ulcerated painless mass. The physical appearance of these tumors can be deceptively benign and can be mistaken for non-malignant conditions. An early diagnosis and aggressive initial treatment remains the mainstay of therapy for a good prognosis. We are presenting eight cases of primary leiomyosarcoma of head and neck region with review of literature and highlight the need for early prudent diagnosis and treatment.

Clinical spectrum and outcome of invasive filamentous fungal infections in children with Type 1 diabetes: North Indian experience

Abstract There is scarcity of data on spectrum and outcome of invasive filamentous fungal infections (IFIs) in children with Type 1 diabetes (T1D) from developing countries. A retrospective review of medical records of children with T1D hospitalized with IFI over the past decade at the Pediatric Endocrinology and Diabetes Unit of a large tertiary care hospital of North India was performed with an aim to study their clinical spectrum, hospital course and final outcome. Of the 10 patients studied, nasal/paranasal involvement was seen in 6 and pulmonary involvement in 5 patients. One patient developed disseminated disease. Majority of the identified mycoses belonged to Class Zygomycetes Order Mucorales. Early surgery along with antifungal therapy helped limit the extension of infection and achieve a good outcome in majority of patients. Two patients died; one with a late diagnosis of pulmonary mucormycosis and the other with disseminated disease. The longterm morbidity in the survivors was minimal. In conclusion, rapid diagnosis followed by a multimodal approach involving aggressive surgical debridement, appropriate antifungal therapy and control of hyperglycemic state is the key to good outcome in this otherwise lethal infection.

Metastasis to submandibular glands in oral cavity cancers: Can we preserve the gland safely?

OBJECTIVE To analyze submandibular gland (SMG) involvement in cases of oral cavity cancers and decide whether to remove submandibular glands while performing neck dissections for oral cavity cancers to decrease the incidence of xerostomia, a common issue post-operatively. METHODS Retrospective analysis of 157 neck dissections out of 204 neck dissections performed for oral cavity carcinomas in the Department of Otolaryngology and Head and Neck Surgery from 2008 to 2013 was done. SMG was bilaterally removed in 6 dissections, hence a total of 163 glands were analyzed. Those involved by tumor in histopathology were further studied for the pattern of involvement. RESULTS 3.68% (6/163) glands showed involvement by the tumor. 9.20% (15/163) showed chronic sialo-adenitic changes. Four of the six involved glands showed direct contiguous spread from primary lesion, one showed extra-capsular spread from level IB lymph nodes and evidence of both modes of spread was seen in one. Evidence of metastasis was not seen in any of the glands (0%). Literature review showed a metastasis rate of 0.096% (2/2074). CONCLUSION Metastatic involvement of submandibular gland is extremely rare. Submandibular gland preservation, in the absence of evidence of gross contiguous involvement, does not affect survival. Hence, SMG can be safely spared during neck dissections for oral cavity squamous cell cancers except in certain situations such as close proximity of the primary lesion to gland, presence of intra-capsular lymph nodes in radiology, gross intraoperative evidence of invasion of the SMG and in salvage surgeries performed in post-irradiated and recurrent cases.

Piston diameter in stapes surgery. Does it have a bearing

Aims and Objectives: This prospective randomized controlled trial was done to study the effect of piston diameter on hearing outcomes after stapedotomy. Materials and Methods: All the patients diagnosed to have otosclerosis were included in the study. A total of 52 patients were studied ranging in age from 18 to 50 years. The subjects were randomized into two groups, that is, 0.4 mm piston (group A) and 0.6 mm piston (group B). The subjects were taken up for small fenestra stapedotomy using either a 0.4 or 0.6 mm piston. The main outcome measures were hearing improvement, air-bone gap closure, and overclosure of air-bone gap. Results: There was no statistical difference in hearing improvement in two different piston diameters, 0.4 and 0.6 mm at speech frequencies. In group A, the air-bone gap improvement in the third follow-up was not significant ( P > 0.05), whereas group B showed a statistically significant improvement ( P = 0.003). The mean overclosure of air-bone gap was better in patients with 0.4 mm piston at speech frequencies and also at 250 Hz. Significantly, overclosure of air-bone gap at higher frequencies (4 and 8 KHz) was seen only with a smaller sized piston. (0.4 mm). Discussion: We analyzed the effect of piston diameter on the hearing results after small fenestra stapedotomy by using similar surgical procedure and similar prosthesis in all patients. Conclusion: There is evidence to suggest that 0.4 mm piston may be better suited for providing optimum hearing results.

Unusual presentation of laryngeal foreign bodies - report of two rare cases.

Aspiration of a foreign body into the respiratory tract is a common and serious problem in childhood but is rare in adults. Two interesting cases in which the diagnosis of foreign body in the larynx was not suspected preoperatively are being reported. A three and half year old female child was diagnosed as a case of bronchitis and was later found to have a metallic spring in the supraglottic region which was removed by direct laryngoscopy under general anesthesia. The other patient, a 32-year-old male, was diagnosed to have a fibrous lesion in the larynx one year previously, and on laryngoscopy a vegetable, spiculated foreign body was found after excising the fibrous lesion on the left false cord. Both the cases are symptom free 18 months after endoscopy.

Early Diagnosis and Surgery is Crucial to Survival Outcome in Rhinocerebral Mucormycosis.

The article by Kolekar [1] made for an interesting read. Their observations on the outcome of rhinocerebral mucormycosis in a predominantly diabetic patient population are succinct and an important addition to the scarce literature on this subject. However we feel that some addition of the crucial clinical data would possibly throw light on the factors responsible for survival outcome of patients. It is widely recognized that a multimodal approach that involves an early diagnosis, aggressive surgical debridement, appropriate antifungal therapy and control of glycemic state improves survival in this invariably fatal condition in patients with diabetes [2, 3]. Of the 4 components of this approach, the first 2 are the most critical but are often the most difficult to achieve [2]. The diagnosis is often delayed due to non-specific symptoms and signs and the need for invasive procedures for confirmation [3]. The sinonasal debridement surgery needs to be performed before the infection spreads to other adjoining areas particularly the brain [2]. In this context, the missing information regarding number of days (mean and range) taken to confirm mucormycosis and the timing of surgical debridement is very important. In our recent study on 4 children with Type 1 diabetes (T1D) and rhinosinus mucormycosis, the mean time to confirm the diagnosis was 3.5 days (range 1–7 days) and endoscopic or open surgery was performed within a week of hospitalization in all patients [4]. Our experience with invasive filamentous fungal infections in patients with T1D, predominantly caused by zygomycetes, is similar with the mean time from presentation to diagnosis of 5.8 ± 4.7 days (range 1–14 days) and debridement surgeries performed immediately after confirmation of diagnosis [5]. The relatively better outcome in our patients was probably a result of earlier diagnosis and treatment effected by a very dedicated team of pediatric endocrinologists, otolaryngologists, mycologists, histopathologists, intensivists, and pediatric surgeons at our center [4, 5]. The overall survival rate of 55 % in the study by Kolekar, although at par with most centers in the world, could be related to the differences in the timings of diagnosis and surgery in their patients. It is possible that the 11 patients who survived were operated earlier as compared to those who died. Thus addition of this crucial information may allow us to determine that the outcome was influenced by the timing of diagnosis and surgery. This information can be easily retrieved from the hospital records of these patients and presented in a subsequent issue of IJOHNS. Also the addition of information regarding the predisposing factors for mucormycosis such as poor glycemic control and ketoacidotic state in the studied patients will be very useful to the readers [5].

To evaluate disparity between clinical and pathological tumor-node-metastasis staging in oral cavity squamous cell carcinoma patients and its impact on overall survival: An institutional study

Background: Accurate clinical staging is important for patient counseling, treatment planning, prognostication, and rational design of clinical trials. In head and neck squamous cell carcinoma, discrepancy between clinical and pathological staging has been reported. Objective: To evaluate any disparity between clinical and pathological tumor-node-metastasis (TNM) staging in oral cavity squamous cell carcinoma (OCSCC) patients and any impact of the same on survival. Materials and Methods: Retrospective chart review from year 2007 to 2013, at a tertiary care center. Statistical Analysis: All survival analyses were performed using SPSS for Windows version 15 (Chicago, IL, USA). Disease-free survival curves were generated using Kaplan-Meier algorithm. Results: One hundred and twenty-seven patients with OCSCC were analyzed. Seventy-nine (62.2%) were males and 48 (37.8%) females with a mean age at presentation 43.6 years (29-79 years). The highest congruence between clinical and pathological T-staging seen for clinical stage T1 and T4 at 76.9% and 73.4% with pathological T-stage. Similarly, the highest congruence between clinical and pathological N-stage seen for clinical N0 and N3 at 86.4% and 91.7% with pathological N-stage. Of clinically early stage patients, 67.5% remained early stage, and 32.5% were upstaged to advanced stage following pathological analysis. Of the clinically advanced stage patients, 75% remained advanced, and 25% were pathologically downstaged. This staging discrepancy did not significantly alter the survival. Conclusion: Some disparity exists in clinical and pathological TNM staging of OCSCC, which could affect treatment planning and survival of patients. Hence, more unified and even system of staging for the disease is required for proper decision-making.

Outcome of Rhino-Sinus Mucormycosis in Children with Type 1 Diabetes

To the Editor: Rhinosinusitis caused by mucormycosis may extend into the orbit and brain and result in high mortality in children with Type 1 Diabetes (T1D) [1]. Rapid diagnosis followed by a multimodal treatment approach involving aggressive surgical debridement, appropriate antifungal therapy and glycemic control improves survival [2, 3]. Hospital records of 4 children aged 7.7±4.4 y (3–12 y) with T1D treated for rhinosinus mucormycosis between March, 2004 and February, 2014 were reviewed. The diagnosis of mucormycosis was based on the presence of broad aseptate hyphae with right-angled branching on microbiological and/or histopatholgical examination of tissue specimens. Contrast enhanced CT scans were done to document rhinosinus involvement if suggestive symptoms/signs like facial swelling and pain, fever, headache, nasal congestion, nasal discharge and sinus tenderness were present. This was followed by endoscopic or open surgical debridement of necrotic tissues, immediate confirmation of diagnosis by the microbiologist, intravenous amphotericin-B deoxycholate and control of hyperglycemic state. All children presented in diabetic ketoacidosis (DKA). Two were diagnosed with T1D recently while 2 were diagnosed for a mean duration of 3 y and had poor metabolic control. Symptoms suggestive of infection included fever in 1, nasal congestion and serosanguineous discharge in 1, and blackish discoloration around nose and facial plane following trauma in 2 patients. Facial swelling was seen in 2 patients while 1 each had swelling of scalp and orbit; 2 had sinus tenderness. Ethmoid, maxillary and frontal sinus involvement was seen on CECT in 4, 3 and 2 patients respectively. Involvement of nasal cavity was noted in all patients on rhinoscopy; one also showed septum destruction. The mean time to confirm the diagnosis of mucormycosis was 3.5 d (range 1–7 d). Endoscopic or open surgery was carried out in 2 patients each; on day 1, day 2, day 3 and day 6 of hospitalisation in 1 patient each. Additional surgeries were performed in 2; excision of frontal lobe abscesses and debridement of necrotic tissue of scalp and face in 1 each. The average time to resolution of DKA was 16.4 h. Mean hospital stay was 49 d (range 16–90 d). One patient is currently undergoing staged plastic reconstruction for facial disfigurement while others have remained asymptomatic over a mean follow up duration of 4.43 y (range 1–9.25 y). Mucormycosis disproportionately affects poorly controlled diabetics due to dysfunction of macrophage phagocytosis, neutrophil chemotaxis and oxidative killing, and ketoacidosis induces a temporary block in binding of iron to transferrin thus providing free iron for D. Dayal (*) : P. Jain Pediatric Endocrinology & Diabetes Unit, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India e-mail: drdevidayal@gmail.com